Utilization Review Nurse

Part-Time Utilization Management RN

Location: Remote – Candidates must reside in PA, NJ, or DE

Schedule: Part-Time | Every Saturday, 9:00 AM–5:00 PM, with potential for additional days

Training: Must be available Monday–Friday, 8:30 AM–4:30 PM for the first 2–3 weeks

Licensure: Active Pennsylvania RN license or Compact RN license that includes Pennsylvania

Position Overview

We are seeking an experienced Registered Nurse to support inpatient Utilization Management on a part-time basis. This RN will conduct telephonic reviews of hospital admissions and continued stays to evaluate medical necessity, appropriate level of care, and discharge readiness. The RN will collaborate with hospital utilization review teams, physicians, case management staff, and Medical Directors to promote high-quality, cost-effective care and ensure members receive services in the most appropriate setting. This role also supports early discharge planning and identifies members who may benefit from Case Management or Disease Management services.

Key Responsibilities

• Perform telephonic utilization review of inpatient hospital admissions and continued stays.
• Apply established medical necessity criteria to determine appropriate level of care, continued stay, and anticipated length of stay.
• Review clinical documentation and treatment plans to evaluate whether inpatient services meet established criteria.
• Communicate with attending physicians and hospital utilization review teams to clarify treatment plans and medical necessity.
• Identify cases that do not meet established criteria and escalate them to Medical Directors for clinical review.
• Present concise and clinically relevant case information to Medical Directors to support utilization decisions.
• Identify hospitalized members who may require discharge planning, home care, or alternative levels of care.
• Collaborate with hospital case management staff, physicians, members, and families to facilitate timely and appropriate discharge.
• Refer appropriate members to Case Management and Disease Management programs.
• Identify potential quality-of-care concerns, including delays in care, and escalate appropriately.
• Maintain timely and accurate documentation of utilization reviews, clinical information, and determinations.
• Ensure utilization management activities comply with applicable state, federal, and accreditation requirements.
• Identify utilization trends or concerns and communicate findings and recommendations to leadership.
• Maintain positive relationships with providers and deliver a high level of customer service.

Qualifications

• Active Pennsylvania RN license or Compact RN license with Pennsylvania privileges required.
• BSN preferred.
• Minimum of 3 years of acute-care clinical experience, preferably within a hospital setting.
• Prior Utilization Management/Utilization Review and/or discharge planning experience required.
• Experience reviewing inpatient admissions, continued stays, medical necessity, and level of care strongly preferred.
• Experience applying clinical or medical necessity criteria within a managed-care environment is highly desirable.
• Strong clinical judgment and ability to evaluate complex medical information.
• Excellent verbal and written communication skills, particularly when interacting with physicians and hospital staff.
• Strong organizational, documentation, and problem-solving abilities.
• Comfortable working independently in a remote environment and using computerized clinical applications.

Schedule Requirements

This is a part-time position specifically supporting Saturday coverage. Candidates must be able to consistently work every Saturday from 9:00 AM–5:00 PM. Additional workdays may become available based on business needs.

Candidates must also be available Monday through Friday from 8:30 AM–4:30 PM for approximately 2–3 weeks at the beginning of the assignment to complete required training.